Diagnostic Accuracy of Plasma Glial Fibrillary Acidic Protein for Differentiating Intracerebral Hemorrhage and Cerebral Ischemia in Patients with Symptoms of Acute Stroke

Foerch, Christian; Niessner, Marion; Back, Tobias; Bauerle, Michael; Marchis, Gian Marco De; Ferbert, A.; Grehl, Holger; Hamann, Gerhard F.; Jacobs, Andréas H.; Kastrup, Andreas; Klimpe, S.; Palm, Frederick; Thomalla, Götz; Worthmann, Hans; Sitzer, Matthias

doi:10.1373/clinchem.2011.172676

Cited by 155 publications

(150 citation statements)

References 40 publications

(49 reference statements)

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“…FNR represents the proportion of patients who would not have been sent to a CSC despite LAO, hence delaying optimal treatment, and FPR represents the proportion of patients who would have been sent to a CSC despite lack of LAO (futile transfers). The highest accuracy (79%; 95% confidence interval, 77-82) was observed for NIHSS score ≥11 (FNR, 27% [22][23][24][25][26][27][28][29][30][31][32]; FPR, 17% [14][15][16][17][18][19][20]), NIHSS score ≥14 (FNR, 39% [34][35][36][37][38][39][40][41][42][43][44]; FPR, 12% [9][10][11][12][13][14]), and RACE score ≥5 (FNR, 33% [28][29][30][31][32][33][34][35][36][37][38]; FPR, 15% [12][13][14]…”

Section: Resultsmentioning

confidence: 99%

“…Prehospital brain and arterial imaging using a mobile stroke unit might be an interesting option for patient triage in selected areas, but it remains to be demonstrated whether this expensive management approach is costeffective in the era of bridging therapy. [25][26][27] Other promising strategies that could help prehospital identification of stroke patients with LAO include serum biomarkers aiming to differentiate AIS and intracerebral hemorrhage 28,29 and automated or telemedicine-guided transcranial ultrasound imaging. 30,31 Our study has several limitations.…”

Section: Discussionmentioning

confidence: 99%

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Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

Turc

Maïer

Naggara

et al. 2016

Stroke

162

138

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Background and Purpose-It remains debated whether clinical scores can help identify acute ischemic stroke patients with large-artery occlusion and hence improve triage in the era of thrombectomy. We aimed to determine the accuracy of published clinical scores to predict large-artery occlusion. Methods-We assessed the performance of 13 clinical scores to predict large-artery occlusion in consecutive patients with acute ischemic stroke undergoing clinical examination and magnetic resonance or computed tomographic angiography ≤6 hours of symptom onset. When no cutoff was published, we used the cutoff maximizing the sum of sensitivity and specificity in our cohort. We also determined, for each score, the cutoff associated with a false-negative rate ≤10%. Results-Of 1004 patients (median National Institute of Health Stroke Scale score, 7; range, 0-40), 328 (32.7%) had an occlusion of the internal carotid artery, M1 segment of the middle cerebral artery, or basilar artery. The highest accuracy (79%; 95% confidence interval, 77-82) was observed for National Institute of Health Stroke Scale score ≥11 and Rapid Arterial Occlusion Evaluation Scale score ≥5. However, these cutoffs were associated with false-negative rates >25%. Cutoffs associated with an false-negative rate ≤10% were 5, 1, and 0 for National Institute of Health Stroke Scale, Rapid Arterial Occlusion Evaluation Scale, and Cincinnati Prehospital Stroke Severity Scale, respectively. Conclusions-Using published cutoffs for triage would result in a loss of opportunity for ≥20% of patients with large-artery occlusion who would be inappropriately sent to a center lacking neurointerventional facilities. Conversely, using cutoffs reducing the false-negative rate to 10% would result in sending almost every patient to a comprehensive stroke center. Our findings, therefore, suggest that intracranial arterial imaging should be performed in all patients with acute ischemic stroke presenting within 6 hours of symptom onset.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

Turc

Maïer

Naggara

et al. 2016

Stroke

162

138

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“…Thus in the early hours after stroke, increased GFAP values could indicate intracerebral haemorrhage not ischaemia. Serum GFAP analysis performed within 4.5 hours of symptom onset can differentiate intracerebral haemorrhage and ischaemic stroke because GFAP levels are increased in patients with intracerebral haemorrhage compared with patients with ischaemic stroke [20]. GFAP has been reported to have high diagnostic accuracy for differentiating intracerebral haemorrhage from ischaemic stroke in patients within the acute phase of stroke symptom onset [21].…”

Section: Discussionmentioning

confidence: 99%

Serum glial fibrillary acidic protein as a marker of brain damage in patients after carotid endarterectomy

et al. 2016

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“…Out of these markers, glial fibrillary acidic protein (GFAP) is so far the most promising for translation into prehospital use. In several hospital cohorts in which samples were collected upon hospital arrival, GFAP has systematically demonstrated high sensitivity and specificity for diagnosing acute ICH [9][10][11]. For example, Foerch et al found sensitivity and specificity values of 84.2 and 96.3% respectively.…”

Section: Past Researchmentioning

confidence: 99%

How Development of Blood Biomarkers Could Benefit Prehospital Management of Acute Stroke

2017

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Stroke is one of the leading causes of death worldwide and leaves most survivors with permanent disability [1,2]. Unfortunately, treatment options of acute stroke are still limited. In developed urban hospitals roughly a third of all ischemic stroke patients receive urgent recanalization therapy, in other words thrombolysis with recombinant tissue plasminogen activator (rtPA) and/or endovascular mechanical thrombectomy for large vessel occlusion (LVO). These treatments are highly efficacious and cost effective, but remain markedly underused [3]. Furthermore, their efficacy is time dependent, with strict therapeutic windows. To enhance the stroke chain of survival, current guidelines recommend a tiered system with acute stroke ready hospitals, primary stroke centers and comprehensive stroke centers to ensure timely initiation of intravenous rtPA with the least possible delay after symptom onset and rapid triage of large vessel occlusions eligible for thrombectomy in a comprehensive stroke center [3].The challenge of stroke diagnostics Time delay in the prehospital phase is the most important reason for missing recanalization therapy. Even for patients meeting the appropriate time window, the median prehospital delay is commonly around 2 h [4]. Emergency medical services (EMS) are challenged with the difficult task of identifying likely acute stroke from the wide range of acutely ill patients and ensuring rapid transport to the appropriate emergency department for immediate neurological examination and diagnostic brain imaging. For now, the main diagnostic groups causing acute strokelike symptoms, namely ischemic stroke, transient ischemic attack, hemorrhagic stroke and conditions mimicking stroke, can only be differentiated with hospital-based tests. EMS are therefore restricted to using simple, nonspecific clinical scales for stroke recognition, preventing them from initiating specific treatments.Mobile CT-equipped ambulances, directed by an onboard stroke neurologist or telemedicine consultation, are one active approach to front load diagnostic and therapeutic procedures and reduce treatment delays [5,6], but require significant resources and are only applicable in urban settings, missing rural areas with longer transportation distances. What is clearly missing is an easier surrogate marker for recognizing the condition of brain tissue (either biochemical or functional) while the described, tiered prehospital stroke management is being advanced. Such markers, including blood troponin measurement and ECG recording, are widely used in the prehospital management of acute myocardial infarction, but are still unavailable for stroke. Useful point-of-care (POC) blood tests would have the significant benefit of being relatively inexpensive and more easily applicable around the world.

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Diagnostic Accuracy of Plasma Glial Fibrillary Acidic Protein for Differentiating Intracerebral Hemorrhage and Cerebral Ischemia in Patients with Symptoms of Acute Stroke

Cited by 155 publications

References 40 publications

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

Serum glial fibrillary acidic protein as a marker of brain damage in patients after carotid endarterectomy

How Development of Blood Biomarkers Could Benefit Prehospital Management of Acute Stroke

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